Every finding on record at S&F Hospice Opco I, LLC

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The hospice did not ensure that the emergency preparedness plan and hazard vulnerability analysis were evaluated and updated at least every two years. Agency policy No. 6-037 The Emergency Management Plan, revised April 2021, stated in part, "The hazard vulnerability analysis (HVA) is evaluated at least every two (2) years." Review of the agency’s EP plan revealed no documented evidence that the HVA was evaluated and updated in 2021, 2022, 2023, and year to date for 2024. During a joint review of the agency’s emergency preparedness plan and interview on 05/30/2024, the Director of Patient Care Services (DPCS) confirmed that the hospice did not have documentation that the emergency preparedness plan hazard vulnerability analysis was evaluated and updated in 2021, 2022, 2023, and year to date for 2024. The DPCS stated, "I'm sure it was updated, but can't find it." A review of the Emergency Management Plan Policy, Emergency Preparedness Plan, and interview revealed the hospice did not ensure that the Emergency Preparedness Plan and Hazard Vulnerability Analysis was evaluated and updated at least every two years.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. The hospice did not ensure the emergency preparedness policies and procedures were reviewed and updated at least every two years. Review of the agency’s Emergency Management Plan, policy No.6-037 with a revised date of April 2021 revealed no documented evidence that the hospice reviewed and updated the EP policies and procedures in 2022, 2023, and year to date for 2024. During a joint review of the agency’s Emergency Management Plan and policy on 05/30/2024, the Director of Patient Care Services confirmed that the hospice did not have documentation that the Emergency Management Plan policy was reviewed and updated in 2022, 2023, and year to date for 2024. A review of the Emergency Management Plan Policy, and interview revealed the hospice did not ensure that the Emergency Preparedness policies and procedures were reviewed and updated at least every two years.

It is required that volunteer services are noted in the plan of care, and documented in the patient record, including the time spent. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed with volunteer visits provided, the hospice did not ensure that volunteer services were documented in the patient record as required by the agency policy. Agency policy No. 4-007 Volunteer Services, stated in part, "Volunteers will document their activities/type of service and time worked on volunteer activity/clinical notes and submit this documentation for the patient's clinical records." Clinical Record 5: The patient elected the hospice benefit on 11/17/2022. During a joint record review and interview on 05/29/2024, the Volunteer Coordinator stated, "Our volunteer visited this patient three times a month in January, February, and March of 2024." The Volunteer Coordinator explained "The volunteers send me the information in an email, but I don't add it to the record." Clinical record review revealed no documented evidence that the volunteer had provided visits to the patient in January, February, and March of 2024. The Volunteer Coordinator agreed that the clinical record did not include documentation that volunteer services had been provided to the patient and documented in the patient record, on paper or electronically. The Director of Patient Care Services (DPCS) was present for the Volunteer Coordinator interview on 05/29/2024. The DPCS agreed that the clinical record did not include documentation of the volunteer services provided as required by agency policy.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 14 (21%) clinical records reviewed, the hospice did not ensure physician orders were signed by the physician as required by agency policy. Agency policy No. 4-028.1 Verification of Physician Orders, stated in part, "signed orders will be in the clinical record within 30 days." Clinical Record 1: The patient elected the hospice benefit on 03/26/2024. Clinical record review revealed no documented evidence that the verbal order plan of care dated 03/26/2024 was signed by the physician, as of the date of record review on 05/28/2024. A total of 63 days and 33 days outstanding. Clinical Record 2: The patient elected the hospice benefit on 04/08/2024. Clinical record review revealed no documented evidence that the verbal order plan of care dated 04/08/2024 was signed by the physician, as of the date of record review on 05/28/2024. A total of 50 days and 23 days outstanding. Clinical Record 9: The patient elected the hospice benefit on 07/18/2023 and was discharged on 08/03/2023. The clinical record contained no documented evidence of a discharge order signed by the physician. During a joint record review and interview on 05/30/2024, the Director of Patient Care Services (DPCS) agreed that there was no documented evidence of the signed physician's orders, either on paper or in the electronic medical record (EMR). The DPCS stated that most orders should be signed in the EMR, but medical records print the plan of care and sends them by email for the Medical Director's signature.” The DPCS agreed that the agency did not have a process in place to ensure orders are signed.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which the patient was a live discharge, the hospice did not ensure a copy of the discharge summary was forwarded to the patient’s attending physician. Clinical Record 9: The patient elected the hospice benefit on 07/18/2023 and was discharged from hospice care on 08/03/2023. Clinical record review revealed no documented evidence that the discharge summary was sent to the patient’s attending physician. Clinical Record 10: The patient elected the hospice benefit on 03/07/2023 and was discharged from hospice care on 04/04/2024. Clinical record review revealed no documented evidence that the discharge summary was sent to the patient’s attending physician. During joint record review and interview on 05/30/2024, the Director of Patient Care Services agreed the clinical record did not include documentation that the discharge summary was sent to the patient’s attending physician.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 1 (100%) home visit observation where the patient resided in a Skilled Nursing Facility (SNF), the hospice did not ensure the SNF was provided with a copy of the patient's most recent hospice plan of care. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 04/08/2024 with a terminal diagnosis of Alzheimer’s disease. The patient resided at a SNF. The hospice plan of care dated 04/08/2024 included documentation of problems, interventions, and goals dated 04/08/2024 including risk for pressure ulcer, risk for infection, risk for malnutrition, risk for falls, psychological and spiritual distress. During the home visit observation with the Chaplain (Personnel Record 6) on 05/29/2024, the SNF’s binder with hospice documents was reviewed with the hospice Director of Patient Care Services (DPCS), who was present at the home visit. The hospice plan of care dated 04/08/2024 was present in the binder, but the plan of care included written documentation related to facility collaboration and delineation of care. The written plan of care in the facility binder dated 04/08/2024 did not include the problems listed on the plan of care dated 04/08/2024 that was found in the clinical record. The problems, interventions, and goals including risk for pressure ulcer, risk for infection, risk for malnutrition, risk for falls, psychological and spiritual distress were not included on the SNF copy of the hospice plan of care. The nursing facility binder with hospice documents included documentation from the hospice to the SNF which stated that the SNF would receive updates to the hospice plan of care every two weeks on Thursdays. The SNF nurse confirmed the binder was where the hospice documentation was kept and the SNF did not have evidence of hospice plan of care updates. The DPCS confirmed the most recent plan of care was missing from the SNF binder. During a joint record review and interview on 05/29/2024, the DPCS, who was present for the home visit, agreed there was no documented evidence that the SNF was provided with the most recent plan of care.

It is required that the hospice maintains an emergency preparedness (EP) training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the following, for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by interviews and personnel record review. 1 of 10 (10%) personnel records reviewed revealed the agency did not ensure initial training in emergency preparedness (EP) was provided to all new hospice employees providing services under arrangement. Staff 8: There was no evidence that Staff 8 (Medical Director) participated in an initial training in EP policies and procedures. The Vice President was interviewed on 10/21/22 and confirmed that there was no evidence that Staff 8 (Medical Director) had participated in the EP training.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by a review of document reviews, interviews and personnel records. 2 of 10 (20%) personnel records reviewed, revealed the hospice failed to ensure an initial orientation was completed for all employees and contracted staff. Document 6 The agency policy number 3-002.1 titled Competency Based Orientation reads in relevant parts, “Orientation is intended to prepare the employee to perform the duties of a new role with a competent level of skill. Competency Based Orientation (CBO) is a method of learning which stresses performance of competencies that relate directly to the employee's job description.” Staff 1: Hire date 4/2021. There was no evidence that Staff 1 (DPCS) had a competency-based orientation. Staff 8 There was no evidence that Staff 8 (Medical Director) had a competency-based orientation. The Vice President and the HR director was interviewed on 10/21/22 and confirmed that there was no evidence that Staff 1 (DPCS) and Staff 8 (Medical Director) had completed an orientation.

It is required that hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document reviews and interviews. 1 of 5 (20%) contracts reviewed revealed the hospice did not ensure the hospice contract required all contracted entities with direct patient contact obtain a criminal background check. Contract 6: The hospice contract did not contain language stating that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. The Vice President was interviewed on 10/21/22 and confirmed that the contract did not contain the required language regarding background checks for contracted employees. He stated the contract department is responsible for writing and updating the agency contracts.